The Ultimate Guide to Population Health

Background of Population Health and Wellness

What is population health?

Population health helps individuals achieve the highest quality of life possible. It recognizes that health is influenced by social, economic, environmental, financial, behavioral, genetic, psychological, medical, cultural, and developmental factors. The practice of population health has broadened in the 15 years since David Kindig and Greg Stoddart proposed their definition as “health outcomes [of a group of individuals], patterns of health determinants, and policies and interventions that link these two.” Today, it also encompasses: Although population health concerns itself with populations, it also focuses on personalized care that puts each individual in the center. To accomplish this goal, private and public agencies collaborate to improve health outcomes and wellness through strategies such as healthy lifestyles, coordinated care, affordable health care, and social support and services. This approach aligns with the Canadian Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) definition of population health: “the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.” ACPH emphasizes “interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.”

What do population health managers do?

Population health and wellness professionals segment populations to provide targeted interventions with the aim of achieving health as defined by the World Health Organization (WHO): “complete physical, mental, and social wellbeing.” They analyze data, considering multiple health determinants such as:

  • Genetics, including age, sex, and race
  • Individual health and behaviors
  • Consumer data
  • Social determinants of health, such as economic factors, employment status, natural and built environment, health care, cultural factors, and social support that can promote or impede optimal health and wellbeing


Along the way, population health and wellness practitioners discover ways to improve the healthcare system, better neighborhoods, and engage individuals. The Centers for Disease Control and Prevention provides training to help individuals improve their population health skills.

2nd Annual Data Review: Social Determinants of Health

Population health versus public health versus community health – what’s the difference?

Population health involves healthcare organizations, community agencies, and wellness companies working together to improve determinants of health with the aim of improving the health and wellbeing of groups of people.

Public health concerns itself with protecting everyone’s health through research, public policy and legislation, education, and social change. These efforts result in less injury and disease, improved health, and lower mortality rates for countries and communities. Examples include healthier built environments, reduced noise pollution, increased access to healthy foods, and effective vaccination programs.

Community health is a subset of public health that focuses on designing and implementing innovative programs that improve the health of specific communities, grouped by geography or based on race or ethnicity. Local agencies, tribal organizations, governmental entities, schools, and non-profits work together to reduce disease and create healthy communities.

What is population health management?

Population health management (PHM) is a strategy primarily used within health and wellness industries to improve health outcomes of specific groups of people. It includes data collection and analytics, risk stratification, care management, engagement, interagency coordination, and outcomes measurement. PHM allows health and wellness professionals to prevent disease, plan treatments and interventions, contain costs, and improve quality of life through multiple touchpoints, including clinical settings, community agencies, and lifestyle management. At times it requires complex care plans that help care managers engage with individuals within targeted populations. Population health tools such as electronic health records and health risk assessments help inform population health companies and practitioners of current health status, risk of future disease, lifestyle behaviors, change readiness, outcomes, and more.

What is integrated population health management?

America’s Health Insurance Plans (AHIP) predicts integrated population health management (IPHM) will revolutionize health care. IPHM relies heavily on interoperability and data analysis. It takes a holistic look at individuals. It combines multiple data points – claims, care management plans, prescriptions, consumer data, biometrics, social determinants of health, community health markers such as walkability scores, and information gleaned from individuals about their health habits and readiness to change – to identify gaps in care, predict chronic disease risk, achieve greater health and wellbeing, and reduce healthcare costs.

What is Wellness?

Wellness is more than the absence of disease. It is about “becoming the healthiest you possible,” according to the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Wellness Institute (NWI) outlines six dimensions of wellness necessary for wellbeing and personal fulfillment: emotional, occupational, physical, social, intellectual, and spiritual. Wellsource founder Dr. Don Hall believed that individuals would flourish when all dimensions of health – body, mind, and community – worked together, and he built the first computerized health risk assessment with this philosophy of optimal health. SAMHSA lists eight dimensions: emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual. WELCOA identifies seven areas of wellness (link opens as PDF): health, meaning, safety, connection, achievement, growth, and resiliency.

Do population health and wellness align?

Population health that focuses on wellness operates on the principle of optimal health for body, mind, and community. It establishes wellness networks that promote wellness components such as social connection, physical activity, healthy diets, and financial wellness. These, in turn, promote physical wellness. On a larger scale, population health and wellness professionals can extend their influence to include businesses and agencies to create community connectedness through events such as free summer concerts, built environments that include green spaces such as nature parks and healing gardens, and a culture that embraces multicultural wellness.

The history of a population health approach to wellness

The concept of wellness is as old as recorded human history. For centuries (perhaps millennia), rulers have had a vested interest in controlling plague and other diseases to ensure stable, established populations that could support and defend the kingdom. Chinese and Hindu modalities focused on achieving wholeness. Greeks and Romans emphasized prevention. These approaches to health have influenced modern-day concepts of population health and wellness. Concerns about the health implications of social conditions such as unemployment can be traced back at least as far as World War II, according to Dr. Szreter in his article investigating the history of population health. Health disparities between rich and poor were observed at least two centuries earlier. But it wasn’t until the latter part of the last century that wellness became the mainstream way to promote healthier lifestyles in populations.

The role of lifestyle medicine in population health and wellness

Lifestyle medicine operates on the belief that the body can protect and heal itself with healthy habits. Preference is given to therapeutic lifestyle changes as a way to prevent, manage, and reverse chronic disease. The TLC Programn (link opens as a PDF) for lowering cholesterol is one example of a lifestyle-as-medicine approach to health care. Medicine is used as a supplemental rather than primary treatment. The American College of Lifestyle Medicine focuses on six behaviors to enhance health: A whole-food, plant-based diet; regular exercise; stress management; healthy relationships; adequate sleep; and avoiding risky substance use, including tobacco cessation and responsible alcohol use. Like the World Health Organization, population health acknowledges that “common, modifiable risk factors” such as substance use, poor diet, and lack of adequate exercise are at the root of many chronic health conditions, including diabetes, heart disease, stroke, and obesity. These perspectives align with lifestyle medicine, which uses healthy lifestyle habits to prevent, manage, and reverse chronic conditions.

Essential population health management tools

Efficient, effective population health depends on data that is managed by information